Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00218730 Renewal 01/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Individual 2's bedroom walls were dirty. Prior to the conclusion of the inspection, the walls were wiped down. Individual 3's curtains were unclean. These curtains were replaced prior to the conclusion of the inspection. Individual 3's wall pads surrounding the bed are dirty and dusty. Prior to the conclusion of the inspection, these wall pads were wiped down. Individual 3's ceiling ventilation cover had a large dust buildup. This vent was wiped down prior to the conclusion of the inspection.Clean and sanitary conditions shall be maintained in the home. A housekeeping checklist was developed that managers will ensure is used by all housekeeping staff; Implementation of this checklist will be checked minimally, once/month. 04/30/2023 Implemented
6400.67(a)The bathroom vanity is peeling and the lower cabinets were nailed shut.Floors, walls, ceilings and other surfaces shall be in good repair. Last year we implemented a plan to address the environmental citations. As a result of this plan, we had about a 35% decrease in physical plant citations. We will continue with the same plan as indicated below. Three times per year an unannounced walk through/inspection will be conducted in all licensed homes by a Residential Director and/or Assistant Vice President of Residential Program. A plan of correction along with a compliance score sheet will be issued to the building manager who will have 30 days to respond and correct all areas that are not in compliance with regulatory standards. The scores will be used to develop a performance improvement plan for the assigned Residential Manager. Residential Directors will not complete unannounced inspection in their assigned programs. 03/16/2023 Implemented
6400.72(a)There are no screens in the bathroom window or in any of the bedrooms on the left side of this building.Windows, including windows in doors, shall be securely screened when windows or doors are open. Last year we implemented a plan to address the environmental citations. As a result of this plan, we had about a 35% decrease in physical plant citations. We will continue with the same plan as indicated below. Three times per year an unannounced walk through/inspection will be conducted in all licensed homes by a Residential Director and/or Assistant Vice President of Residential Program. A plan of correction along with a compliance score sheet will be issued to the building manager who will have 30 days to respond and correct all areas that are not in compliance with regulatory standards. The scores will be used to develop a performance improvement plan for the assigned Residential Manager. Residential Directors will not complete unannounced inspection in their assigned programs. 03/16/2023 Implemented
6400.182(c)Individual 1 does not have a dresser in their bedroom and their clothes are being stored in the hallway entry closet in the living room. There is no documentation of this in their individual support plan. Individual 2's individual plan has not been updated to reflect that there is a newly written and implemented behavior plan that was put in place in December of 2022. The most recent individual plan notated that this individual does not have a behavior support plan. Individual 2 and 3 had wall pads on the walls surrounding their bed. There is no mention of this in the individual or behavior support plan.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The residential monthly environmental checklist was updated to note modifications to an individual's environment. A data base is being developed to create a central location to note modified rooms so, that plans can be easily crosschecked. Process to take place before bedroom modifications will be formalized to ensure team consensus and necessary plan documentation. 03/17/2023 Implemented
SIN-00199977 Renewal 01/31/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)Individual # 2's bedroom window is not in good repair - it is sealed shut and cannot be opened . there is no ventilation in the bedroom. Staff stated there was a work order. The maintenance request to fix the window was made via email after the inspection was completed. The emails were dated 2.2.22 & 2.3.22 to the maintenance staff. Screens, windows and doors shall be in good repair. Fixed on 2/25/2022. On 3/2/22 Residential Manager walked 15 Woodland on and confirmed that the window was fixed and it opens. 03/31/2022 Implemented
6400.111(c)The fire extinguisher was in the dining area next to the kitchen - no fire extinguisher found in the actual kitchen area. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). Fire extinguisher has been mounted in the kitchen. Residential Manager walked 15 Woodland on 3/2/22 and confirmed that fire extinguisher is in the kitchen. 03/02/2022 Implemented
6400.142(a)The dental examination for Individual #4 was not completed semi annually; 4/27/21-11/16/21.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Dental Center closed because of pandemic. Appointments were scheduled as dental office re-opened as exemplified by the immediate visit for individual #4 on 11/16/2021. On 3/3/2022, a chart review was conducted by the Manager of QA & UR and confirmed that all remaining residents in this home are fully compliant with dental examinations. 03/01/2022 Implemented
6400.240(b)Dishwasher during the Wash cycle reads 95 degrees- Final rinse cycle 111 degrees. A mechanical dishwasher shall use hot water temp 140 degrees in the wash cycle and 180 degrees in the final rinse cycle. The dishwasher needs to be repaired/or replaced. A mechanical dishwasher shall use hot water temperatures exceeding 140°F in the wash cycle and 180°F in the final rinse cycle or shall be of a chemical sanitizing type approved by the National Sanitation Foundation. 15 Woodland has a Hobart Chemical sanitizing dishwasher. The required wash temperature is 120 degrees and 120 degrees for rinse cycle. On 3/2/22 the Residential Manager walked 15 Woodland on and confirmed that the chemical dishwasher wash and rinse cycles are at 120 degrees. 03/02/2022 Implemented
6400.181(f)The annual assessment for individual #4 was not provided 30 days prior to ISP meeting. Letter sent 10/27/21, meeting was held 11/15/21.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Care Coordinator retrained on timelines of completion. Director of Care Coordination and Assistant Director of Care coordination. His Care Coordinator was retrained on 3/1/22. 03/01/2022 Implemented
6400.185(5)Individual #1 and Individual #3 bedrooms had gym mats lining the wall, staff states to prevent head banging. This information is not included in the individual support plan.The individual plan, including revisions, must include the following: Risks to the individual's health, safety or well-being, behaviors likely to result in immediate physical harm to the individual or others and risk mitigation strategies, if applicable.Upon review of the ISP dated 3/1/21, page 5, paragraph 6, Individual 1's "bedroom walls have been padded because when upset he may kick or head butt his walls". For individual #3, Addendum was completed for Resident Assessment and updated at the ISP meeting. As of 3/1/22, the Director of Care Coordination confirmed that all other remaining residents are in compliance. 03/01/2022 Implemented
SIN-00183413 Renewal 02/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)There was a spray container located in the kitchen cabinet that was not labeled or in its original container.Poisonous materials shall be stored in their original, labeled containers. Spray container was removed during inspection. 05/31/2021 Implemented
6400.72(b)The screen located in Individual#2's Rm.#10 was not in good repair. (the screen was bent and did not fit properly). The screen located in the dining room/common area was not in good repair. (the screen was bent and did not fit properly). Screens, windows and doors shall be in good repair. A work order has been submitted on 3/19/2021, estimated date of completion 4/8/2021. Attachment # 1 05/31/2021 Implemented
6400.32(d)The syrup located in the kitchen cabinet had expired 8/10/2020.An individual shall be treated with dignity and respect.The syrup was removed on 2/8/2021. 02/15/2021 Implemented
6400.32(h)Individual#1 in Rm#9 had no dresser and all of the individual's belongings were stored in the lobby closet unlocked in the lobby. No waiver was provided at time of inspection.An individual has the right to privacy of person and possessions.Assessment will be updated. 05/31/2021 Implemented
SIN-00133736 Renewal 02/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.195(f)Individual #1's Restrictive Behavior Support plan dated 12/1/17 required five men face up floor control restraint. However, on 12/18/17, six men face up floor control restraint was implemented.The restrictive procedure plan shall be implemented as written. Individual #1's Restrictive Behavior Support Plan has been updated on 6/14/18 (attachment #1). The Behavior Support Plan will no longer indicate the maximum number of staff who can implement a restraint. The Behavior Support Plan will state that the staff necessary to maintain the safety of the resident. The clinician writing the Behavior Support Plan will be primarily responsible for reviewing the plan as well as the use of restraint in the day program and residence. The clinician will provide feedback to the Clinical Director and the 6400 BMRC committee who will monitor the plans and insure that they are written according to Woods policy and 6400 regulations. 06/14/2018 Submitted
SIN-00108178 Renewal 02/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)The outside trash can did not have a lid. Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The trash can lid was replaced during the walk through inspection. The Program Supervisor completes an environmental walk thru of the home minimally once per month. Any noted repairs will be submitted to the appropriate department. If repairs cannot be completed, appropriate action will be taken to replace the item. The environmental checklist will then be submitted to the Residential Manager for review. If observed at any time, Program Supervisor are to report any issues to the Residential Manager so that immediate action can be taken. 02/08/2017 Implemented
6400.141(c)(14)Individual #1's annual physical examination, dated 11/29/16, did not contain information pertinent to diagnosis in case of an emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The Nursing department revised the physical form to include information pertinent to diagnosis or treatment in case of an emergency. As new physicals are completed, the new form will be utilized. (see attachment #3) 02/13/2017 Implemented
6400.213(1)(i)Individual #1's record did not document identifying marks. Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.Individual #1's resident assessment was due during this review it was revised to include identifying marks ( see attachment #1). Letters were sent out with the assessment (see attachment #2). The Program Specialist will ensure that going forward all assessments should include the identifying marks and if a resident does not have any, it will be noted. 03/21/2017 Implemented
SIN-00091279 Renewal 10/26/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)The brown recliner in the kitchen area has a torn fabric back. Furniture and equipment shall be nonhazardous, clean and sturdy. The recliner belonged to an individual who no longer resides at Woods. It was taken with the individual when they moved. 11/15/2015 Implemented
6400.181(f)The assessment for individual # 1, dated 5/7/15 was sent to the SC on 7/23/15 after the ISP meeting on 6/2/15. (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Director of Case Management will track the submission of the Assessment to assure it is submitted in a timely manner. Due dates of supporting assessments will be given to Area Supervisors to ensure their timely submission to the Program Specialist. 12/01/2015 Implemented
6400.181(d)(4)Invitation letters were not sent 30 days before the ISP meeing of 6/2/15. The invitation letters were sent 5/15/15.The plan lead shall develop, update and revise the ISP according to the following: An invitation shall be sent to plan team members at least 30 calendar days prior to an ISP meeting. The program specialist was counseled by Director of Case Management on the expectation that all invitation letters must be sent out 30 days before the ISP. 11/01/2015 Implemented
6400.183(5)No staff were trained on Individual # 1 behaviour support plan dated 5/28/15 prior to working with the individual. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. All staff working with Individual #1 were trained on his Behavior Support Plan by Clinician on 11/03/2015 and 11/04/2015. The Clinician received an Employee Counseling Statement on 12/14/2015 by the Clinical Director reminding him of the importance of training staff within two weeks of approval by Behavior Rights Committee. (See Attachment B and C) 12/15/2015 Implemented
6400.183(6)(iii)The Restrictive Procedure Plan dated 5/28/15 did not include a target date for achieving the outcomes.The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: The method and timeline for eliminating the use of restrictive procedures. The Clinician received an Employee Counseling Statement on 12/14/2015 by the Clinical Director reminding him to always include the goals of his plan before giving it to Administrative Assistant for distribution (see attachment C). 12/14/2015 Implemented
6400.186(c)(4)(iii)The restrictive plan on May 28, 2015 was not submitted to the SC for modification of the ISP. The program specialist shall make a recommendation regarding the following, if applicable: The modification of an outcome or service to support the achievement of an outcome in which no progress has been made. An ISP meeting was held for A.D. on 6/2/15 (client was admitted on 3/3/15) in which A.D.'s Supports Coordinator attended and signed off on the signature form. During this meeting, A.D.'s clinician, John Gorrell, discussed A.D.'s increased behavior and the BSP that was approved by BMRC on 5/28/15. The Supports Coordinator was made aware of A.D.'s behaviors when she attended the meeting held on 6/2/15. In addition, the completed Behavior Support Plan was sent out to her on 6/19/15. All corresponding information was presented and discussed to inspector D.P. and during the licensing inspection. (see attachment A) 10/30/2015 Implemented
SIN-00063876 Renewal 07/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature in the bathtub was 124°. Hot water temperatures in bathtubs and showers may not exceed 120°F. Brandi Lindner, Residential Director, sent a maintenance email request to have the water temperature lowered. On 8/5/14, the maintenance department corrected this issue and the right bathroom temperature was 117 degrees, the kitchen temperature was 118 degrees, and the left bathroom was 117 degrees. (See attachment B) Monthly water temperatures will continue to be taken by the housekeeper of the building and reviewed each month for compliance by the Residential Manager or Program Supervisor. If the temperature readings are out of compliance, the Residential Manager or Program Supervisor will notify the Woods' maintenance department to have the temperatures adjusted accordingly. 08/01/2014 Implemented
6400.182(d)(1)Individual #1's ISP was not updated annually, ISP was dated 7/10/13 was not updated until 8/9/14.The plan lead shall develop, update and revise the ISP according to the following: The ISP shall be initially developed, updated annually and revised based upon the individual's current assessment as required under § § 2380.181, 2390.151, 6400.181 and 6500.151 (relating to assessment). During the BHSL annual 2013 licensing inspection, a discussion occurred between BHSL licensing representatives and Woods Services Quality Improvement department. The ISP implementation date was always started on the day that the team meeting was held. A question came up in how the ISP could be implemented on the same day as the team meeting since it was just being approved. That being said, a new process was implemented, beginning September 2013, where the ISP implementation date was changed going forward to be 30 days after the team meeting giving enough time to type up the plan and distribute it accordingly. C.T.'s ISP meeting dates of July 10, 2013 and then July 9, 2014 met the yearly regulatory guideline; however, the goals were not implemented until August 9, 2014 from the July 2014 meeting. This was due to it occurring within the transition phase of the new process. (See attachments A) Program Specialists will continue to monitor ISP meeting dates to ensure compliance with the regulations. The ISP will remain effective for the next 12 months unless a critical revision is required. [The ISP meeting will be completed on a date that allows for the ISP to be finalized and implemented within one year of the previous ISP effective date. LAC 1/26/15] 08/01/2014 Implemented
6400.185(a)Individual #1's ISP was not implemented there was lapse between 7/11/14 -8/9/14. The ISP shall be implemented by the ISP's start date. During the BHSL annual 2013 licensing inspection, a discussion occurred between BHSL licensing representatives and Woods Services Quality Improvement department. The ISP implementation date was always started on the day that the team meeting was held. A question came up in how the ISP could be implemented on the same day as the team meeting since it was just being approved. That being said, a new process was implemented, beginning September 2013, where the ISP implementation date was changed going forward to be 30 days after the team meeting giving enough time to type up the plan and distribute it accordingly. C.T.'s ISP meeting dates of July 10, 2013 and then July 9, 2014 met the yearly regulatory guideline; however, the goals were not implemented until August 9, 2014 from the July 2014 meeting. This was due to it occurring within the transition phase of the new process. (See attachments A) Program Specialists will continue to monitor ISP meeting dates to ensure compliance with the regulations. The ISP will remain effective for the next 12 months unless a critical revision is required.[The ISP meeting will be completed on a date that allows for the ISP to be finalized and implemented within one year of the previous ISP effective date. LAC 1/26/15] 08/01/2014 Implemented
SIN-00156315 Renewal 04/29/2019 Compliant - Finalized